Application Form – Daily Care Support

application form

DAILY CARE SUPPORT SERVICES, INC.

APPLICATION FOR EMPLOYMENT
(Please Fill Out Completely)

Date of Application

Email:

Print Full Name

Home Phone:

Mobile:

Address

City

State

Zip Code

Position Applied For

APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation,
Incomplete applications will not be considered. This company will use the or any other legally protected status. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

INSTRUCTIONS TO APPLICATION

A. Please fully and accurately complete the Application for Employment. Information given in the application to verify your previous employment and background.

B. The Application for Employment will be considered inactive after 90 days. If you wish to be considered after that time, you must complete a new Application for Employment.

C. Resume will not be accepted in lieu of completed applications but will be considered supplemental information.

D. If you are hired, proof of eligibility will be required to verify your lawful right to work in the United States. (Form I - 9 Work Eligibility)

EMPLOYMENT APPLICATION FORM

PART A: PERSONAL INFORMATION

Title (Mr, Miss, Mrs , Others Please Specify)

First Name(s):

Last Name:

Home Address:

Correspondence Address (If different:

Home Telephone:

Work Telephone:

May we contact you at work?

Yes

Are you eligible to work in the United States?

Yes

Do you have a work permit or a right to work Visa?

Yes

PART B: EDUCATION AND TRAINING

High School Name and Address

Dates Attended:

Diploma Received?

Yes

Area of Study

Colleges/ Training Schools

Dates Attended:

Diploma Received?

Yes

Area of Study

Professional trainings/ qualifications with dates and levels obtained

PART C: PRESENT AND PAST WORK HISTORY

Present or most recent employer and address:

Dates (month/ year)

Position Held and Duties:

Reason for leaving

Starting Salary:

Ending Salary:

May we contact this employer?

Yes

If no, please indicate reason.If no, please indicate reason.

PART D: WORK HISTORY

Give details of your work history with the most recent listed first: ONE

Employer and address:

Dates (month/ year)

Position Held and Duties:

Reason for leaving

Starting Salary:

Ending Salary:

May we contact this employer?

Yes

If no, please indicate reason.If no, please indicate reason.

PART D: WORK HISTORY

Give details of your work history with the most recent listed first: TWO

Employer and address:

Dates (month/ year)

Position Held and Duties:

Reason for leaving

Starting Salary:

Ending Salary:

May we contact this employer?

Yes

If no, please indicate reason.If no, please indicate reason.

PART E: SUPPORTING STATEMENT

Please indicate all relevant experience, skills and work history that relate to the job description for which you have applied. Please print clearly. All illegible entries will not be considered.

(attach additional sheets if necessary)

Maximum file size: 516MB

PART F: MEDICAL HISTORY

Can you lift a weight of seventy pounds?

Yes

If no, please indicate your reasonIf no, please indicate your reason

PART: CHARACTER REFERENCES

Please list three-character references of which we may contact.

Name

Relationship

Years of Affiliation

Telephone number

Name

Relationship

Years of Affiliation

Telephone number

Name

Relationship

Years of Affiliation

Telephone number

PART H: DECLARATION

By signing below, I,

on the date of

hereby certify that all information included in the above application is true and valid to the best of my knowledge.I also understand that misrepresentation or falsification of the information provided above will result in my immediate disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery.

Name

Date

DAILY CARE SUPPORT SERVICES, INC.
CONFIDENTIAL AGREEMENT

READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT

I agree that except at the request and for the benefit of Daily Care Support Services, Inc I will not disclose to anyone or use for my own purposes any of Daily Care Support Services, Inc confidential or proprietary information, either during or after my employment. I understand and agree that Daily Care Support Services, Inc bidding, costs, pricing and marketing information and techniques, customer names and information, and employee name and information are confidential and proprietary Daily Care Support Services, Inc. I certify that this application contains no willful misrepresentation or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I authorized Daily Care Support Services, Inc to contact all sources to verify the information on this application. I understand that any falsification, misrepresentation, or fraudulent information provided by me in connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate discharge.
I understand that this application is not a contract of employment. I authorized and requested my former employers, references, and educational institutions which have information about me, to give Daily Care Support Services, Inc all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and release such former employers, references, and educational institutions from any liability or claim relating to such release of information and opinions. I also authorized and request federal, state, and local governmental agencies to release Daily Care Support Services, Inc any information requested, concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.

Signature of applicant:

Clear

Date

RELEASE OF INFORMATION

I hereby authorized all prior employers, schools, credit bureaus, social security Administration. Law enforcement agencies and investigative agencies to give Daily Care Support Services, Inc all information concerning my previous employment and any pertinent information they may have personal or otherwise, concerning my qualifications for the position applied for. I release to Daily Care Support Services, Inc and all its employees form all liability for any damage that may result from furnishing information to Mercy Community Integration Program, Inc I also release to Daily Care Support Services, Inc and all its employees from all liability for any damage that may result from reliance on the information furnished. I understand that if a consumer investigative report is requested, I have the right under the Fair Credit Reporting Act to request in writing, within a reasonable time, a complete and accurate disclosure of the nature and scope of the investigation. This written request should be addressed to the location where this application is filed.

Full Name (Please Print)

Social Security Number

Signature of Applicant

Clear

Date

DAILY CARE SUPPORT SERVICES, INC.
CONFLICT OF INTEREST

I acknowledge that I have read the company policy statement concerning conflict of interest and I hereby declare that neither I, nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company that would constitute a violation of that company policy. If I terminate my employment with Daily Care Support Services, I will not work for any patient I have worked for with Daily Care Support Services for a period of two years or pay a fine of $2500.00. All assignments are considered Per Diem, there are no full or part time positions with Daily Care Support Services, Inc. due to the demands of the patients, and change in patient’s condition and needs. Furthermore, I declare that during my employment, I shall continue to maintain my affairs in accordance with the requirements of said policy

Employee Name

Signature

Clear

Date

USCIS FORM I9

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions. ANTI DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.

Last Name (Family Name)

First Name (Given Name)

Middle Initial (if any)

Other Names Used (if any)

Address (Street Number and Name)

Apt No

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

U.S. Social Security Number

Employee's Email Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of
this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1. A citizen of the United States

2. A noncitizen national of the United States (See Instructions.)

3. A lawful permanent resident (Enter USCIS or A-Number.)3. A lawful permanent resident (Enter USCIS or A-Number.)

4. An alien authorized to work until (exp. date, if any)4. An alien authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

Form I-94 Admission Number

Foreign Passport Number and Country of Issuance

Signature

Clear

Today's Date (mm/dd/yyyy)

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

OR

LIST B

Check here if you used an alternative procedure authorized by DHS to examine documents.

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

DAILY CARE SUPPORT SERVICES, INC.

APPLICATION FOR EMPLOYMENT (Please Fill Out Completely)

APPLICATION FOR EMPLOYMENT

INSTRUCTIONS TO APPLICATION

A. Please fully and accurately complete the Application for Employment. Information given in the application to verify your previous employment and background.

B. The Application for Employment will be considered inactive after 90 days. If you wish to be considered after that time, you must complete a new Application for Employment.

C. Resume will not be accepted in lieu of completed applications but will be considered supplemental information.

D. If you are hired, proof of eligibility will be required to verify your lawful right to work in the United States. (Form I - 9 Work Eligibility)

EMPLOYMENT APPLICATION FORM

PART A: PERSONAL INFORMATION

PART B: EDUCATION AND TRAINING

PART C: PRESENT AND PAST WORK HISTORY

PART D: WORK HISTORY

Give details of your work history with the most recent listed first: ONE

PART D: WORK HISTORY

Give details of your work history with the most recent listed first: TWO

PART E: SUPPORTING STATEMENT

Please indicate all relevant experience, skills and work history that relate to the job description for which you have applied. Please print clearly. All illegible entries will not be considered.

PART F: MEDICAL HISTORY

PART: CHARACTER REFERENCES

Please list three-character references of which we may contact.

PART H: DECLARATION

DAILY CARE SUPPORT SERVICES, INC.CONFIDENTIAL AGREEMENT

READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT

RELEASE OF INFORMATION

DAILY CARE SUPPORT SERVICES, INC.CONFLICT OF INTEREST

USCIS FORM I9

Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.

If you check Item Number 4., enter one of these:

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

OR

LIST B

Pages

Services

Employees

APPLICATION FOR EMPLOYMENT
(Please Fill Out Completely)

DAILY CARE SUPPORT SERVICES, INC.
CONFIDENTIAL AGREEMENT

DAILY CARE SUPPORT SERVICES, INC.
CONFLICT OF INTEREST